A caval homograft for Budd-Chiari syndrome due to inferior vena cava obstruction

Transjugular intrahepatic portosystemic shunt (TIPS) is the standard treatment of Budd-Chiari syndrome (BCS) non responsive to medical therapy. However, patients with inferior vena cava (IVC) obstruction proximal to the atrium do not benefit from TIPS and a surgical approach is mandatory. We report the case of BCS due to intrapericardial IVC obstruction. We describe a novel surgical approach using a fresh caval homograft. An attempt to balloon dilatation of the IVC obstruction was complicated by right atrial disruption with tamponade and ventricular fibrillation. Lately, the patient successfully underwent a reconstruction of the cavo-atrial continuity by the interposition of a fresh caval homograft, a novel surgical approach never described before for BCS. Further follow-up revealed progressive reduction and resolution of ascites, and overall clinical improvement. IVC obstruction near to the atrium can be surgically approached with a new technique consisting in inferior vena cava resection and replacement with a caval homograft.

植入瓣膜与患者不匹配对单纯主动脉瓣狭窄患者主动脉瓣置换术后心脏事件和中期死亡的影响

Background -Prosthesis-patient mismatch(PPM) occurs when the effective orifice area(EOA) of the prosthesis being implanted is too small in relation to body size, thus causing abnormally high transvalvular pressure gradients. The objective of this study was to examine the midterm impact of PPM on overall mortality and cardiac events after aortic valve replacement in patients with pure aortic stenosis. Methods and Results -The indexed EOA(EOAi) was estimated for each type and size of prosthesis being implanted in 315 consecutive patients with pure aortic stenosis. PPM was defined as an EOAi ≤0.80 cm2/m2 and was correlated with overall mortality and cardiac events. PPM was present in 47%of patients. The 5-year overall survival and cardiac event-free survival were 82±3%and 75±4%, respectively, in patients with PPM compared with 93±3%and 87±4%in patients with no PPM(P≤0.01). In multivariate analysis, PPM was associated with a 4.2-fold(95%CI, 1.6 to 11.3) increase in the risk of overall mortality and 3.2-fold(95%CI, 1.5 to 6.8) increase in the risk of cardiac events. The other independent risk factors were history of heart failure, NHYA class III-IV, severe left ventricular hypertrophy, and absence of normal sinus rhythm before operation. Conclusions -PPM is an independent predictor of cardiac events and midterm mortality in patients with pure aortic stenosis undergoing aortic valve replacement. As opposed to other risk factors, PPM may be avoided or its severity may be reduced with the use of a preventive strategy at the time of operation.

Coronary artery bypass grafting in diabetic patients: Should we still use the saphenous vein graft? A review of literature in the past 15 years

The burden of diseases associated with diabetes mellitus is dramatic: adults with diabetes mellitus are 2 to 4 times more likely to have cardiovascular diseases than those without it, and at least 65% will die because of diabetes complications. The revascularization strategy in these types of patients included percutaneous coronary interventions with bare metal stents or medicated stents and surgical coronary artery bypass grafting (CABG), but it is well known that in the diabetic patient with two or more vessel disease, the surgical strategy allows the best mid- and long- term results. Moreover, benefits of CABG surgery are limited by life expectancy of the most common type of graft, the saphenous vein (SV). Nearly 40 years after the introduction of bypass surgery, the rate of vein graft failure remains at high levels. Several arterial conduits had been studied as alternative conduits to SV: the Right Internal Thoracic Artery (RITA), the Radial Artery (RA), the Gastroepiploic Artery (GEA) and the Inferior Epigastric Artery (IEA), 40 years ago. The aim of our article is to review the scientific literature of the past 15 years to answer this question: are we ready to treat the diabetic patient, with a completely arterial revascularization, avoiding the use of the great saphenous vein grafts?

Source, Triggers and Clinical Implications of Hyperlactemia in Patients Undergoing Mitral Valve Surgery Using Custodiol Cardioplegia

Background: Postoperative blood hyperlactaemia is an indicator of organ anaerobic metabolism and is associated with morbidity after cardiac surgery. This prospective study aims to explore the source, triggers and clinical implications for hyperlactaemia in patients undergoing mitral valve surgery using Custodiol cardioplegia. Methods: Twenty consecutive elective patients undergoing open-heart surgery for mitral valve repair/replacement using Custodiol (based on Bretschneider’s HTK-solution) cardioplegia were recruited. A serial measurement of arterial blood lactate was performed. Pre-, intra-and post-operative clinical data were obtained and cardiac injury was determined by serial plasma measurement of postoperative release of CK-MB. Results: There were no in-hospital deaths. Most of the patients (n = 16) needed intraoperative direct current cardioversion to treat ventricular arrhythmias or post-operative vasopressors (n = 13) to treat vasoplegia. There was significant cardiac injury as determined by the marked increase of serum CK-MB (p 0.05). A significant (p 0.05) increase in blood lactate was found to follow a biphasic profile. The first peak (from 0.54 ± 0.03 to 1.3 ± 0.07 mM) was observed immediately following the release of the aortic cross-clamp and remained high for 1 hour. This was followed by a second peak at 12 hours post-operatively (1.9 ± 0.2 mM). The second rise in lactate was seen only in patients that required post-operative vasopressors (1.3 ± 0.2 vs 2.2 ±0.3 mM, p 0.05), in whom a significant late decrease in CVP was also observed (12.2 ± 1.0 to 7.7 ± 1.0 for 1 and 12 hours postoperative, respectively). Hyperlactaemia did not correlate with any other variables including CK-MB levels, cross-clamp or cardiopulmonary bypass time. Conclusions: In patients undergoing mitral valve surgery with Custodiol cardioplegia there is marked cardiac injury and a biphasic release of blood lactate. The initial peak in lactate occurs immediately following unclamping the aorta and is likely to be of organ (e.g. heart and lungs) origin. A second peak is only seen in patients requiring postoperative vasopressors to treat vasoplegia. Hyperlactaemia following mitral valve surgery with Custodiol cardioplegia does not seem to be related to myocardial injury as expressed by CK-MB release.

Non-intrusive data-driven ROM framework for hemodynamics problems

Reduced order modeling(ROM)techniques are numerical methods that approximate the solution of parametric partial differential equation(PED)by properly combining the high-fidelity solutions of the problem obtained for several configurations,i.e.for several properly chosen values of the physical/geometrical parameters characterizing the problem.By starting from a database of high-fidelity solutions related to a certain values of the parameters,we apply the proper orthogonal decomposition with interpolation(PODI)and then reconstruct the variables of interest for new values of the parameters,i.e.different values from the ones included in the database.Furthermore,we present a preliminary web application through which one can run the ROM with a very user-friendly approach,without the need of having expertise in the numerical analysis and scientific computing field.The case study we have chosen to test the efficiency of our algorithm is represented by the aortic blood flow pattern in presence of a left ventricular(LVAD)assist device when varying the pump flow rate.